Politics, water management and infrastructure.

While modern water management has been central to the achievement of a range of beneficial social outcomes, it has increasingly drawn criticism for its disconnection from democratic decision-making, hindering efforts to develop more resilient systems. This paper examines how an experiment with more resilient water infrastructure politicized centralized water management focusing, in particular, on a stormwater re-use 'third-pipe' system at a large residential development in Auckland, New Zealand. Through analysis of resident and expert views on safety, cost and security, the paper attends (1) to the ways in which techno-managerial water management was contested and, thus, politicized through the implementation of the third pipe, and (2) how the mobilization of techno-managerial discourses by water management authorities delegitimized the third-pipe system, rendering it ultimately inoperable. While our case study was thwarted by the de-politicizing apparatus of water management authorities, such experiments offer precedents, resources and hope for more democratic systems of water management. This article is part of the theme issue 'Urban flood resilience'.

Treating ecological deficit with debt: The practical and political concerns with green bonds.

Recent years have witnessed calls to 'unlock' private capital and unleash a wave of green finance that can address the global environmental crisis. To this end, ample resources are being invested in the rapidly growing market for green bonds: a debt security that links finance to projects that claim environmental benefits. This has placed green bonds in the vanguard of green finance, with a promise of treating our ecological deficit with debt. Such positioning demands close scrutiny of their obstacles, opportunities, and socio-environmental impacts. This paper contributes to this task with a multi-disciplinary review of green bond media articles, grey literature, and academic research. The paper has three key aims. It seeks to provide an introduction to green bonds for scholars who are not fluent in finance. Secondly, it attempts to provide a platform for further green finance research by delineating the major practical and political concerns with green bonds. Finally, it aims to widen our view of the green bond market by putting applied and critical research agendas into direct conversation. The paper concludes by calling for more explicit analysis of what green bonds can actually do; centring an expanded notion of greenwashing in green bond discourse; and pursuing more comparative, case driven research on green bond market development.

Shopping on the Public and Private Health Insurance Marketplaces: Consumer Decision Aids and Plan Presentation.

BACKGROUND: The design of the Affordable Care Act's (ACA) health insurance marketplaces influences complex health plan choices. OBJECTIVE: To compare the choice environments of the public health insurance exchanges in the fourth (OEP4) versus third (OEP3) open enrollment period and to examine online marketplace run by private companies, including a total cost estimate comparison. DESIGN: In November-December 2016, we examined the public and private online health insurance exchanges. We navigated each site for "real-shopping" (personal information required) and "window-shopping" (no required personal information). PARTICIPANTS: Public (n = 13; 12 state-based marketplaces and HealthCare.gov ) and private (n = 23) online health insurance exchanges. MAIN MEASURES: Features included consumer decision aids (e.g., total cost estimators, provider lookups) and plan display (e.g., order of plans). We examined private health insurance exchanges for notable features (i.e., those not found on public exchanges) and compared the total cost estimates on public versus private exchanges for a standardized consumer. RESULTS: Nearly all studied consumer decision aids saw increased deployment in the public marketplaces in OEP4 compared to OEP3. Over half of the public exchanges (n = 7 of 13) had total cost estimators (versus 5 of 14 in OEP3) in window-shopping and integrated provider lookups (window-shopping: 7; real-shopping: 8). The most common default plan orders were by premium or total cost estimate. Notable features on private health insurance exchanges were unique data presentation (e.g., infographics) and further personalized shopping (e.g., recommended plan flags). Health plan total cost estimates varied substantially between the public and private exchanges (average difference $1526). CONCLUSIONS: The ACA's public health insurance exchanges offered more tools in OEP4 to help consumers select a plan. While private health insurance exchanges presented notable features, the total cost estimates for a standardized consumer varied widely on public versus private exchanges.

Twitter sentiment predicts Affordable Care Act marketplace enrollment.

BACKGROUND: Traditional metrics of the impact of the Affordable Care Act (ACA) and health insurance marketplaces in the United States include public opinion polls and marketplace enrollment, which are published with a lag of weeks to months. In this rapidly changing environment, a real-time barometer of public opinion with a mechanism to identify emerging issues would be valuable. OBJECTIVE: We sought to evaluate Twitter's role as a real-time barometer of public sentiment on the ACA and to determine if Twitter sentiment (the positivity or negativity of tweets) could be predictive of state-level marketplace enrollment. METHODS: We retrospectively collected 977,303 ACA-related tweets in March 2014 and then tested a correlation of Twitter sentiment with marketplace enrollment by state. RESULTS: A 0.10 increase in the sentiment score was associated with an 8.7% increase in enrollment at the state level (95% CI 1.32-16.13; P=.02), a correlation that remained significant when adjusting for state Medicaid expansion (P=.02) or use of a state-based marketplace (P=.03). CONCLUSIONS: This correlation indicates Twitter's potential as a real-time monitoring strategy for future marketplace enrollment periods; marketplaces could systematically track Twitter sentiment to more rapidly identify enrollment changes and potentially emerging issues. As a repository of free and accessible consumer-generated opinions, this study reveals a novel role for Twitter in the health policy landscape.

Typing myalgic encephalomyelitis by infection at onset: A DecodeME study.

Background: People with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) experience core symptoms of post-exertional malaise, unrefreshing sleep, and cognitive impairment. Despite numbering 0.2-0.4% of the population, no laboratory test is available for their diagnosis, no effective therapy exists for their treatment, and no scientific breakthrough regarding pathogenesis has been made. It remains unknown, despite decades of small-scale studies, whether individuals experience different types of ME/CFS separated by onset-type, sex or age. Methods: DecodeME is a large population-based study of ME/CFS that recruited 17,074 participants in the first 3 months following full launch. Detailed questionnaire responses from UK-based participants who all reported being diagnosed with ME/CFS by a health professional provided an unparalleled opportunity to investigate, using logistic regression, whether ME/CFS severity or onset type is significantly associated with sex, age, illness duration, comorbid conditions or symptoms. Results: The well-established sex-bias among ME/CFS patients is evident in the initial DecodeME cohort: 83.5% of participants were females. What was not known previously was that females tend to have more comorbidities than males. Moreover, being female, being older and being over 10 years from ME/CFS onset are significantly associated with greater severity. Five different ME/CFS onset types were examined in the self-reported data: those with ME/CFS onset (i) after glandular fever (infectious mononucleosis); (ii) after COVID-19 infection; (iii) after other infections; (iv) without an infection at onset; and, (v) where the occurrence of an infection at or preceding onset is not known. Among other findings, ME/CFS onset with unknown infection status was significantly associated with active fibromyalgia. Conclusions: DecodeME participants differ in symptoms, comorbid conditions and/or illness severity when stratified by their sex-at-birth and/or infection around the time of ME/CFS onset.

Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS) is a chronic disease that affects an estimated 250,000 people in the UK. Its defining symptom is post-exertional malaise, an excessive delayed worsening of symptoms following even minor physical or mental exertion. For those with it, ME/CFS means disability and poor quality of life. DecodeME is a research study which is looking for DNA differences between people with ME/CFS and people without any health problems. People with ME/CFS who take part in DecodeME complete a questionnaire that assesses their symptoms and whether they will then be invited to donate a DNA sample. This paper analyses the answers to this questionnaire; we will publish results of the DNA analysis separately. So far, more than 17 thousand people with ME/CFS have completed the DecodeME questionnaire. Their answers help us to address the question: "Are there different types of ME/CFS linked to different causes and how severe it becomes?" Results show that people with ME/CFS do not form a single group reporting similar symptoms and additional medical conditions. Instead, participants who had an infection at the start of their ME/CFS reported a different pattern of symptoms and conditions compared to those without an infection. It is well known that most people with ME/CFS are females. What was not clear previously was that females tend to have more additional health conditions. Also, being female, being older and being over 10 years from ME/CFS onset all make it more likely that someone is more severely affected by their ME/CFS. These findings could indicate that by studying people with different ME/CFS onset-types separately ­ rather than analysing all people with ME/CFS together ­ it will be easier to understand what is going wrong.

Graduates' perceptions of the role and availability of career guidance at medical school.

BACKGROUND: Very limited research has investigated the extent or the impact of career guidance provided to medical students. AIMS: We aimed to explore the perceptions of recent graduates of Irish medical schools of the availability, accessibility and utility of both formal and informal career advice resources during their university experience. METHODS: The study population was junior doctors in their first postgraduate year. Both an online questionnaire, distributed nationally, and a focus group were conducted to explore the topic via mixed-methods research methodology. Findings were synthesised, with quantitative and qualitative analysis applied as appropriate. RESULTS: Graduates of all medical schools within Ireland were invited to participate in the survey. Questionnaire responses were received from 117 junior doctors enrolled in intern networks across the country, from a potential population of 580 (response rate 20.2%). Five interns participated in the focus group discussion. The existence of a formal career advice programme at medical school was reported by 10.3% of questionnaire participants (12/117). Fifty-three per cent (62/117) did not recall any career advice sessions being organised by their university. Only 7.7% (9/117) perceived that adequate career advice had been available at medical school. Focus group participants reiterated a lack of career guidance but highlighted the importance of authentic clinical exposure to a specialty to complement guidance programmes. CONCLUSIONS: Career guidance at medical school is sparse, and recent graduates feel this should be improved upon.

Increasing age influences uterine integrity, but not ovarian function or oocyte quality, in the cheetah (Acinonyx jubatus).

Although the cheetah (Acinonyx jubatus) routinely lives for more than 12 yr in ex situ collections, females older than 8 yr reproduce infrequently. We tested the hypothesis that reproduction is compromised in older female cheetahs due to a combination of disrupted gonadal, oocyte, and uterine function/integrity. Specifically, we assessed 1) ovarian response to gonadotropins; 2) oocyte meiotic, fertilization, and developmental competence; and 3) uterine morphology in three age classes of cheetahs (young, 2-5 yr, n = 17; prime, 6-8 yr, n = 8; older, 9-15 yr, n = 9). Ovarian activity was stimulated with a combination of equine chorionic gonadotropin and human chorionic gonadotropin (hCG), and fecal samples were collected for 45 days before gonadotropin treatment and for 30 days after oocyte recovery by laparoscopy. Twenty-six to thirty hours post-hCG, uterine morphology was examined by ultrasound, ovarian follicular size determined by laparoscopy, and aspirated oocytes assessed for nuclear status or inseminated in vitro. Although no influence of age on fecal hormone concentrations or gross uterine morphology was found (P > 0.05), older females produced fewer (P < 0.05) total antral follicles and oocytes compared to younger counterparts. Regardless of donor age, oocytes had equivalent (P > 0.05) nuclear status and ability to reach metaphase II and fertilize in vitro. A histological assessment of voucher specimens revealed an age-related influence on uterine tissue integrity, with more than 87% and more than 56% of older females experiencing endometrial hyperplasia and severe pathologies, respectively. Our collective findings reveal that lower reproductive success in older cheetahs appears to be minimally influenced by ovarian and gamete aging and subsequent dysfunction. Rather, ovaries from older females are responsive to gonadotropins, produce normative estradiol/progestogen concentrations, and develop follicles containing oocytes with the capacity to mature and be fertilized. A more likely cause of reduced fertility may be the high prevalence of uterine endometrial hyperplasia and related pathologies. The discovery that a significant proportion of oocytes from older females have developmental capacity in vitro suggests that in vitro fertilization and embryo transfer may be useful for "rescuing" the genome of older, nonreproductive cheetahs.

Spatial, temporal and socioeconomic patterns of illicit drug use in New Zealand assessed using wastewater-based epidemiology timed to coincide with the census.

AIMS: A discrete experiment in wastewater-based epidemiology (WBE) timed to coincide with the census was used to investigate the spatial, temporal and socioeconomic patterns of illicit drug consumption in Auckland, Bay of Plenty and Canterbury. METHODS: For seven consecutive days over census week (6 March 2018), wastewater was sampled from seven wastewater treatment plants and analysed for methamphetamine, cocaine (as benzoylecgonine) and 3,4-methylenedioxymethamphetamine (MDMA). Detailed sewer catchment maps were developed and, together with the data, were used to analyse drug consumption. RESULTS: Methamphetamine (mean 22.9 ± 9.9 doses/day/1000 people) was the most consumed drug, followed by MDMA (mean 1.7 ± 1.5 doses/day/1000 people) and cocaine (mean 0.5 ± 0.3 doses/day/1000 people). Methamphetamine consumption (and to a lesser extent MDMA) was high compared to that reported for Western nations, while cocaine consumption was extremely low. Cocaine and MDMA consumption were higher in cities compared to towns. In contrast, methamphetamine was typically higher in towns. Cocaine and MDMA were consumed more at weekends. Methamphetamine use was more consistent throughout the week. MDMA and cocaine were correlated with socioeconomic advantage, whereas methamphetamine was correlated with disadvantage. CONCLUSIONS: This paper contextualises illicit drug use in three New Zealand regions containing 18.3% of the national population and confirms the pervasiveness of methamphetamine consumption in New Zealand towns. This work demonstrates how WBE can be used to explore the socioeconomic dimensions of drug use when duly combined with other data sources like censuses.

Quantifying nicotine and alcohol consumption in New Zealand using wastewater-based epidemiology timed to coincide with census.

INTRODUCTION: Accurate and timely information about nicotine and alcohol consumption is needed to inform effective policy. Wastewater-based epidemiology provides an opportunity to quantify consumption, which can complement traditional data collection methods. METHODS: Wastewater samples were collected from seven wastewater treatment plants on seven consecutive days in three regions of New Zealand during the same week as the national census (6 March 2018). Samples were analysed for nicotine and alcohol metabolites using liquid chromatography-tandem mass spectrometry. Detailed catchment maps were developed and per capita consumption calculated. RESULTS: Observed nicotine consumption (mean 1528 ± 412 cigarettes/day/1000 people) was similar to national sales data. Observed alcohol consumption (mean 1155 ± 764 standard drinks/day/1000 people) was lower than estimated using alcohol availability data. Consumption of nicotine and alcohol was generally higher in the Bay of Plenty and Canterbury compared to Auckland, mirroring trends in the New Zealand Health Survey. Intra-regional differences were observed and the patterns could not be attributed to urbanisation alone. Nicotine consumption was consistent throughout the week whereas alcohol consumption often peaked at the weekend. Nicotine consumption was correlated with neighbourhood-deprivation. There was little correlation for alcohol. DISCUSSION AND CONCLUSIONS: Wastewater-based epidemiology provides a quantitative dataset that complements traditional methods of investigating nicotine and alcohol consumption. Timing data collection to coincide with the census helps to account for the influence of population mobility when normalising consumption.

The Great Gamble? A Mixed-Methods Study of Factors In˜fluencing Medical Students in Specialty Choice.

BACKGROUND: Career planning remains relatively unexplored as a domain of medical education. Our aim was to explore the career planning journey undertaken by medical students. Results Approximately one third of participants had decided their future specialty. Important factors in career choice were 'interest in specific [specialty] aspects,' 'work-life balance,' 'personality type' of others in the specialty, an enjoyable experience on rotation and role models. Negative influential factors included poor conduct of doctors encountered and negative portrayals of specialities by practicing doctors. Conclusion The undergraduate and early postgraduate periods are formative times in career planning for junior doctors. Students and interns/FY1s are strongly influenced by doctors in the clinical setting, and clinicians should be aware of this power to exert both positive and negative influence.

An evaluation of self-perceived knowledge, attitudes and behaviours of UK oncologists about LGBTQ+ patients with cancer.

INTRODUCTION: Over one million people in the UK identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning). Research has shown that this population experience differing cancer risk factors compared with non-LGBTQ+ patients and persistent inequalities in cancer care. Literature concerning the knowledge of oncologists of this group's healthcare needs is limited; our study aimed to evaluate knowledge, attitudes and behaviours of UK oncologists about LGBTQ+ patients. METHODS: A 53-question survey was delivered via a secure online platform. Questions covered respondent demographics, knowledge, attitudes and behaviours with the majority of responses on a Likert scale. Oncologists were recruited via email from professional bodies and social media promotion. Informed consent was sought and responses fully anonymised. Multifactorial ordinal logistic regression and Fisher's exact test were used to assess for interactions between demographics and responses with Holm-Bonferroni multiple testing correction. RESULTS: 258 fully completed responses were received. Respondents had a median age of 43 years (range 28-69); 65% consultants and 35% registrars; 42% medical, and 54% clinical, oncologists. 84% felt comfortable treating LGBTQ+ patients but only 8% agreed that they were confident in their knowledge of specific LGBTQ+ patient healthcare needs. There were low rates of routine enquiry about sexual orientation (5%), gender identity (3%) and preferred pronouns (2%). 68% of oncologists felt LGBTQ+ healthcare needs should be a mandatory component of postgraduate training. CONCLUSIONS: This survey showed that UK oncologists feel comfortable treating LGBTQ+ patients but may fail to identify these patients in their clinic, making it more difficult to meet LGBTQ+ healthcare needs. There is self-awareness of deficits in knowledge of LGBTQ+ healthcare and a willingness to address this through postgraduate training. Educational resources collated and developed in accordance with this study would potentially improve the confidence of oncologists in treating LGBTQ+ patients and the cancer care these patients receive.

'Mentoring the Gap' for Junior Doctors: Promoting an under-utilised resource back to centre-stage.

This article was migrated. The article was marked as recommended. Mentoring in medicine is not a new concept. However in recent years it has been sadly neglected and consigned to the wings of the medical education theatre. In this age of disparate clinical teams, disillusionment and shift working, the NHS needs to proactively nurture and develop junior doctors to support them on their career path. In this paper, we argue that effective mentoring is key to achieving this goal. Context and methods: The researcher is a Core Medical Trainee (CMT) and set up a near-peer mentoring programme between Foundation Year (FY) doctors and CMTs. A focus group was conducted and inductive thematic analysis was used to analyse the resulting transcript. Thematic maps demonstrating the benefits and barriers to mentoring were produced. Results: Results demonstrated that mentoring was useful for mentees' personal development in terms of networking opportunities, pastoral support and the sharing of experiences. Positivity and camaraderie were key to an effective mentoring partnership, whilst rota clashes posed a significant barrier. Dangers identified included mentors adhering too tightly to a 'mentoring formula' and encouraging mentees to become 'carbon copies' of themselves. Conclusions: This study has provided a valuable insight into the benefits of mentoring for junior doctors. Recommendations include promotion and active creation of formal mentoring programmes, and integration of formal mentoring training into the CMT curriculum.

For Third Enrollment Period, Marketplaces Expand Decision Support Tools To Assist Consumers.

The design of the Affordable Care Act's online health insurance Marketplaces can improve how consumers make complex health plan choices. We examined the choice environment on the state-based Marketplaces and HealthCare.gov in the third open enrollment period. Compared to previous enrollment periods, we found greater adoption of some decision support tools, such as total cost estimators and integrated provider lookups. Total cost estimators differed in how they generated estimates: In some Marketplaces, consumers categorized their own utilization, while in others, consumers answered detailed questions and were assigned a utilization profile. The tools available before creating an account (in the window-shopping period) and afterward (in the real-shopping period) differed in several Marketplaces. For example, five Marketplaces provided total cost estimators to window shoppers, but only two provided them to real shoppers. Further research is needed on the impact of different choice environments and on which tools are most effective in helping consumers pick optimal plans.

Seeing Health Insurance and HealthCare.gov Through the Eyes of Young Adults.

PURPOSE: We describe young adults' perspectives on health insurance and HealthCare.gov, including their attitudes toward health insurance, health insurance literacy, and benefit and plan preferences. METHODS: We observed young adults aged 19-30 years in Philadelphia from January to March 2014 as they shopped for health insurance on HealthCare.gov. Participants were then interviewed to elicit their perceived advantages and disadvantages of insurance and factors considered important for plan selection. A 1-month follow-up interview assessed participants' plan enrollment decisions and intended use of health insurance. Data were analyzed using qualitative methodology, and salience scores were calculated for free-listing responses. RESULTS: We enrolled 33 highly educated young adults; 27 completed the follow-up interview. The most salient advantages of health insurance for young adults were access to preventive or primary care (salience score .28) and peace of mind (.27). The most salient disadvantage was the financial strain of paying for health insurance (.72). Participants revealed poor health insurance literacy with 48% incorrectly defining deductible and 78% incorrectly defining coinsurance. The most salient factors reported to influence plan selection were deductible (.48) and premium (.45) amounts as well as preventive care (.21) coverage. The most common intended health insurance use was primary care. Eight participants enrolled in HealthCare.gov plans: six selected silver plans, and three qualified for tax credits. CONCLUSIONS: Young adults' perspective on health insurance and enrollment via HealthCare.gov can inform strategies to design health insurance plans and communication about these plans in a way that engages and meets the needs of young adult populations.

A case study on rheumatoid arthritis.

At a time when many managed care organizations increasingly shift costs to patients through tiered formularies and widening copay differentials, biologic agents represent a significant clinical and financial challenge unlikely to be managed optimally with tiered formularies and greater patient cost sharing. The information discussed in this article is intended for healthcare professionals involved with rheumatoid arthritis therapy, including but not limited to physicians in both the inpatient and outpatient setting, and for other managed care professionals, including medical directors, pharmacy directors, long-term care decision makers, nurses, pharmacists, and case managers.

Putting Health Back Into Health Insurance Choice.

What are the barriers to voluntary take-up of high-deductible plans? We address this question using a large-scale employer survey conducted after an open-enrollment period in which a new high-deductible plan was first introduced. Only 3% of the employees chose this plan, despite the respondents' recognition of its financial advantages. Employees who believed that the high-deductible plan provided access to top physicians in the area were three times more likely to choose it than employees who did not share this belief. A framed field experiment using a similar choice menu showed that displaying additional financial information did not increase high-deductible plan take-up. However, when plans were presented as identical except for the deductible, respondents were highly likely to choose the high-deductible plan, especially in a two-way choice. These results suggest that informing plan choosers about high-deductible plans' health access provisions may affect choice more strongly than focusing on their financial advantages.

Can consumers make affordable care affordable? The value of choice architecture.

Tens of millions of people are currently choosing health coverage on a state or federal health insurance exchange as part of the Patient Protection and Affordable Care Act. We examine how well people make these choices, how well they think they do, and what can be done to improve these choices. We conducted 6 experiments asking people to choose the most cost-effective policy using websites modeled on current exchanges. Our results suggest there is significant room for improvement. Without interventions, respondents perform at near chance levels and show a significant bias, overweighting out-of-pocket expenses and deductibles. Financial incentives do not improve performance, and decision-makers do not realize that they are performing poorly. However, performance can be improved quite markedly by providing calculation aids, and by choosing a "smart" default. Implementing these psychologically based principles could save purchasers of policies and taxpayers approximately 10 billion dollars every year.